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Ep. 24: Alopecia Areata & You

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Ep. 24: Alopecia Areata & You

May 27, 2022

You may have heard recently that celebrities including Jada Pinkett-Smith, Tyra Banks, and Matt Lucas have Alopecia Areata, but what do you know about this type of hair loss condition? In today's episode, Skincast hosts Luke Johnson, MD and Michelle Tarbox, MD break down the causes of this physically harmless and painless autoimmune disease, as well as the options for patients who wish to treat it.


Dr. Tarbox: Hello and welcome to "Skincast," the podcast for people who want to learn how to take the very best care of the skin they're in.

I'm Dr. Michelle Tarbox, a dermatologist and dermatopathologist at Texas Tech University Health Sciences Center in beautiful sunny Lubbock, Texas. And joining me is . . .

Dr. Johnson: Hey Hello, everybody. This is Dr. Luke Johnson. I am a pediatric dermatologist and general dermatologist with the University of Utah in Salt Lake City.

Dr. Tarbox: So what are we going to talk about today, Luke?

Dr. Johnson: Hey Today, we're going to talk about alopecia areata. This is a condition that affects 1% to 3% of the population, so it's fairly common. So again, that means if you just grabbed 100 random people off the surface of the earth, 1 to 3 of them would have alopecia areata.

And alopecia areata shows up as bald spots. Usually they're little circles. Usually they're on the scalp, though people with alopecia areata can also lose hair elsewhere on their body.

Dr. Tarbox: And there are some celebrities that have it, right, Luke?

Dr. Johnson: Hey Yes. As you might guess, since 1% to 3% of people have it, there are some celebrities who have it. One of them recently brought the condition into public viewing, front and center, Jada Pinkett Smith. I don't pay too much attention to this stuff, but I was told that there was slapping of movie stars at the Oscars and it was a big deal. I've heard the term Slapgate, I think.

But apparently, Jada Pinkett Smith has the condition. So do Tyra Banks, Selma Blair, Christopher Reeve, and an actor named Matt Lucas. I'm a big nerd, so I know that Matt Lucas was in "Doctor Who," and I also saw him in "The Great British Baking Show" when I was walking past my wife while she was watching "The Great British Baking Show."

Dr. Tarbox: Yeah. And I think that Slapgate somewhat, as some people are calling it, emphasizes the emotional nature of hair loss. So hair loss can be a condition that has a significant psychological impact on the patient, and something, especially for female patients but also for male patients, that sometimes causes quite a lot of anxiety or potentially depression, sometimes avoiding social interaction because they don't want to have to explain.

Dr. Johnson: Hey Alopecia, by the way, is just the medical term for hair loss, and alopecia areata is this particular type of hair loss. There are lots of other reasons for people to lose their hair. Androgenetic alopecia, for example, is the medical term for just male-pattern hair loss or female-pattern hair loss.

But all hair loss is pretty crummy. People like their hair. I like my hair. I hope it doesn't fall out. But if you notice that you or your child have started to get circular bald spots, there's a pretty good chance it's alopecia areata because there's not a lot of other stuff that looks exactly like that.

Dr. Tarbox: And that last name of the condition, the areata part of alopecia areata, comes from a Latin term meaning area and referring to the vacantness of it, so an empty space. And so while other kinds of alopecia lead to generalized thinning sometimes, a completely hairless patch is less common, disregarding the kind of large central patch that might happen in advanced androgenetic alopecia. So a completely hairless patch anywhere on the scalp might be this condition.

Dr. Johnson: Hey It's an autoimmune disease. It's caused by the immune system attacking the hair follicles. Why does somebody's immune system decide to attack their hair follicles but somebody else's doesn't? We don't really know. Kind of like some other conditions we've discussed like vitiligo. We assume there's a genetic predisposition, so something about somebody's genes puts them at risk for it. And then something kind of triggers to make those genes become active, and then the immune system is off to the races.

Dr. Tarbox: And those triggers can be variable. The most common one that patients express is stress-related. Often, you'll see this condition arise maybe in a child whose family is moving or whose parents are going through a divorce. You may see it in young patients who are going through college entrance exams, but it can also just occur all by itself.

Dr. Johnson: Hey And whenever we talk about stress making things worse, I like to emphasize that it's not your fault that you're so stressed, and because you're not dealing with your stress appropriately, that's why your hair is falling out, because that's nonsense. Everybody has got stress and sometimes these genes just play tricks on us.

Good news is that there are treatments for it, if you want to treat it. Like we talked about with vitiligo, there are some people who could be really, really bothered by the appearance of their hair not being there. And then there are some people who just don't care and live their life kind of ignoring it. And there are some people who kind of like the way that it looks and wear it loud and proud.

So that's one reason I think it's kind of helpful to talk about these celebrities because some of them, like Matt Lucas, seem to wear it loud and proud and serve as advocates for patients who have the condition.

Dr. Tarbox: Yeah. But there are lots of treatments for it. So some of the things that we usually start with are topical steroids. These medications are relatively easy to use, relatively simple to obtain most of the time, and are relatively predictable in how they're going to behave on the skin.

Often, we'll either use a liquid solution or a gel. The scalp has got hair on it, so putting a cream on that ends up with kind of a lot of crusty cream mess on your hair and people tend not to like that.

In patients who have a more coiled hair structure, sometimes we'll use an ointment base because the moisturizing nature of that might help prevent hair breakage that an alcohol-based solution might exacerbate.

Dr. Johnson: Hey Good news is that whether we treat it or not, the odds are that the hair will recover. Unlike some other conditions that we've discussed, this one usually kind of just gets better on its own in the majority of cases. Probably at least two-thirds of cases, if we do nothing, in a year the hair will all be back to where it was before the condition began.

So this is what I tell patients and their parents. I say, "We do have some medicines that we can use that can probably help the hair come back faster, but if you're like most people with the condition, it's going to come back whether we do anything or not."

Of course, if you look up the condition on the internet, you'll find the dramatic situations where that was not the case, but in most people, it comes back on its own. So that's another reason why treatment might not be necessary.

Dr. Tarbox: But if you do have a condition that is getting worse or not improving, there are a lot of options. So we start with the topicals. If those are not working and the patient is amenable and capable of tolerating it, we sometimes will do intralesional-injected steroids, meaning we take a syringe that has the medicine inside it and we actually inject the medicine directly into the patch of hair loss. This is sterile medicine that's intended for injection, so this should only be done in a physician's office who has experience with the treatment, but it can be very effective.

Dr. Johnson: Hey If you've listened to other episodes of "Skincast," you probably have heard us talking about immunosuppressant medications. So these are fancy medicines that you take by mouth or even that you get injected, which turn down the immune system overall. They have names like methotrexate and cyclosporine and mycophenolate and azathioprine.

We can use them in dermatology when the immune system is rudely being overactive in particular parts of the skin. But as we have mentioned before, they have significant side effects, as you might guess, since they have such an effect on the entire body, so we prefer not to use them. That said, most people who take them don't really have any significant side effects and it can be really helpful to help stop hair loss in this condition.

Dr. Tarbox: Other things that can potentially be useful? There are some specialized treatments that are also used in physician offices, including platelet-rich plasma where blood is actually taken from the patient, centrifuged, and then the platelet-rich fraction of that is re-injected into the area of hair loss.

Red light therapy has also been beneficial for some patients. Not every red light device is equal. You actually do want something that has near-infrared wavelengths. So the most effective ones that are available over-the-counter to the lay populace is the Theradome, the Hairmax laser comb, and some versions of the iRestore. So those are different red-light-emitting devices that can be helpful for hair loss of all kinds and also for alopecia areata.

Counter-irritants is another thing that might be done in a physician's office where they may apply a little sensitizing agent to part of the skin and then use a lower concentration of that to elicit a very low-level contact dermatitis, which sort of switches the type of inflammation that's happening in that skin away from the kind that's attacking the hair follicles to the kind that makes a dermatitis. And so you sort of trade one problem that's a more problematic issue for a slightly less troublesome problem that's easier to treat.

And then there's a special kind of laser-like device that's called a laser but it's not really a laser. It's called the excimer laser. And it has a UV wavelength that can be used with the targeted hand piece to help treat patients who have these patches of hair loss.

What are some other medications that are coming up, Luke?

Dr. Johnson: Hey There are some new medications in therapeutic trials for this condition. There is a type of medicine called a JAK inhibitor, which shows a lot of promise even for people who've had alopecia for a long time.

So kind of like we discussed with vitiligo, the longer the hair loss is present, the harder it is to regrow the hair. But some patients who have had hair loss for even 10 years or more, again this particular type of hair loss, alopecia areata, have regrown their hair with these medicines. And they look pretty safe. So they're not FDA approved yet, but my guess is that they will be in the next one to two years.

Of course, some people who have more extensive hair loss, as you might guess, prefer to disguise or camouflage the areas of hair loss with hairpieces and extensions and things like that.

Dr. Tarbox: And most of the time with the camouflaging agents, those are going to be something that you clip into the hair or put on top of the hair. There are camouflage powders such as XFusion or Viviscal fibers or something called Toppik. Those work well for most types of alopecia.

If you have a completely hairless patch, though, they won't work because the way they work is to attach themselves through an electrostatic charge to hair shafts. And if you don't have any hair shafts in that area, there's nothing for that kind of sprinkle powder to attach to. So it might have to be more of a scalp applied dye or a hairpiece.

Dr. Johnson: Hey But look at all the medications that are available. So if you or somebody you know has alopecia areata, and you want to treat it, then you should probably see a doctor, perhaps a dermatologist, because there are lots of treatments we can use.

Dr. Tarbox: Is there anything else that people who have alopecia areata need to worry about, Luke?

Dr. Johnson: Hey Well, like with other autoimmune diseases, if you've got one, then there's a chance you might have another. Most people who have alopecia areata do not have other immune diseases. But if they do, the most common one is thyroid. So perhaps your doctor would want to check a little bit of lab work, especially if you have other symptoms of thyroid disease.

And like other autoimmune diseases, we can't change your genes yet. I guess CRISPR-Cas9 might be coming. But for now, if your hair does come back, which again is the norm, it might come out again. So a common story is little 6-year-old kid develops alopecia areata during a move, hair comes back just fine, and then that same kid becomes a college student and again loses patches of hair while studying for finals. It might happen.

Dr. Tarbox: One thing I want to emphasize is that sudden patchy hair loss is pretty much never normal. So it should probably be seen by a physician, because there are also other conditions that may cause patches of hair loss on the scalp.

There's something called alopecia neoplastica, which is actually a condition where some kind of cancer actually metastasizes to the skin of the scalp because of the specialized structure of some of the veins in that part of our body. And you can end up with a lumpy patch of alopecia. If you have a patch of hair loss that's got lumps underneath it, you need to see a doctor quickly because that could be something called alopecia neoplastica.

There are also certain infectious conditions that can cause patchy hair loss, including tinea capitis, which is basically ringworm on the scalp. So a fungal infection on the scalp can cause hair loss and should be treated with medical attention.

And then hopefully not too commonly, but syphilis can also cause some patchy hair loss on the scalp and is a condition you would definitely want to see a physician for if you had concern that might be something you had.

Dr. Johnson: Hey And I mentioned that most patients with alopecia areata, the hair just recovers on its own. Sadly, that is not the case for everybody. So perhaps a third or a bit less of patients will progress. So these are the patients you're likely to see if you Google alopecia areata image search. And there are individuals who then lose all the hair on their scalp, or even all the hair on their head including eyelashes and eyebrows, or even all of the hair on their body as well.

And when it's that extensive, it gets special names. So alopecia totalis is the name if you lose all the hair on your head and alopecia universalis if you lose all your body hair.

Again, some people are not bothered by it. It's not a medically dangerous condition. Some people choose to just go on "Great British Baking Show" as a host. But if you do notice that your hair or your child's hair is progressing to that degree and you want to do something about it, you want to see a doctor sooner rather than later so we can implement some of these therapies.

Dr. Tarbox: Well, I hope everybody has gotten to learn a whole lot about alopecia areata today. If you're really interested in alopecia areata, and you want to dive deeper, you might want to listen to our other podcast.

Dr. Johnson: Hey We talk about all kinds of stuff on this other podcast, including alopecia areata and a lot of different dermatologic diseases and treatments and things. It's called "Dermasphere." We say it is the podcast by dermatologists for dermatologists and for the dermatologically curious. So if you are a dermatology nerd, like we are, then you can come hang out with us there on Apple Podcasts or wherever you get your podcasts.

Dr. Tarbox: And of course, we also want to give our special thanks to our institutions.

Dr. Johnson: Hey Yes, thanks to the University of Utah for supporting the podcast and thanks to Texas Tech for lending us Michelle. You can find our "Skincast" archives on Apple Podcasts or wherever you are finding your podcasts. And you can find the next episode of "Skincast" hopefully in two weeks. We'll see you then.